European Eating Disorders Review Eur. Eat. Disorders Rev. 15, 323–339 (2007) Eating One’s Words: Part III. Mentalisation-Based Psychotherapy for Anorexia Nervosa—An Outline for a Treatment and Training Manual Finn Ska˚rderud1,2* 1Faculty of Health and Social Studies, Lillehammer University College, Norway 2Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway This paper presents a new outline for psychotherapy with per- sons with anorexia nervosa. ‘Model on mentalisation’ is the intellectual and empirical framework for this contribution. Men- talisation is defined as the ability to understand feelings, cogni- tions, intentions and meaning in oneself and in others. The capacity to understand oneself and others is a key determinant of self- organisation and affect regulation, and is acquired in early attach- ment relationships. Impaired mentalisation is documented and described as a central psychopathological feature in anorexia ner- vosa. Psychotherapeutic enterprise with individuals with com- promised mentalising capacity should be an activity that is specifically focused on the rehabilitation of this function, with special emphasis on how the body is representing mental states. The paper describes psychotherapeutic goals, stances and tech- niques. It is intended that this outline will be further developed into manuals as a basis for therapy, training and research. Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords: anorexia nervosa; embodiment; mentalisation; psychotherapy; psychoanalysis INTRODUCTION developing therapeutic techniques for this disorder. There is a general agreement that working with The aim of this paper is to propose an outline for anorexia nervosa may be challenging. Ambivalence psychotherapeutic approaches to anorexia nervosa, about recovery is a central feature. Patients and to introduce a ‘model on mentalisation’ (Allen with anorexia rarely seek treatment on their & Fonagy, 2006) as an intellectual framework for own initiative (Rosenvinge & Kuhlefelt-Klusmeier, 2000), the motivation to change is low and/or unstable (Geller, Williams, & Srikameswaran, 2001), * Correspondence to: Prof. Finn Ska˚rderud, MD, Institute for approximately one-half of the patients drop out of eating disorders, Kirkeveien 64 B, N-0364 Oslo, Norway. Tel: þ47-918-19-990. Fax: þ47 22025700. treatment (Vandereycken and Pierloot, 1983) and in E-mail: fi[email protected] a review Fairburn (2005) states that treatment Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.817 324 F. Ska˚rderud outcome is generally poor. Despite research efforts the self from without. Anorexia nervosa is described there is a striking paucity of empirical evidence as a disorder of self- and affect regulation, and the supporting any method of treatment for anorexia concretistic symptoms essentially serve the function nervosa (Woodside, 2005). of maintaining the cohesion and stability of a This is the third and final part of three companion tenuous sense of self. papers, ‘Eating one’s words I, II and III’. The series The idea that severe eating disorders are essen- aims at furthering the understanding of the specific tially self disorders has emerged gradually as psychopathology of anorexia nervosa, based on clinicians and researchers have recognised the need research (Part I, Ska˚rderud, 2007a), apply and to revise earlier conceptual models because of develop relevant theory (Part II, Ska˚rderud, serious limitations in their ability to explain the 2007b) and outline psychotherapy on this empirical clinical features of the eating disorders and to devise and theoretical basis (Part III). The recommen- effective therapies (Taylor, Bagby and Parker, 1997). dations for therapy follow the principle that Already the pioneer in eating disorders, Bruch psychotherapeutic interventions should be tailored (1962) stated that the core problem lies in a deficient directly to psychopathological processes. sense of self and involves a wide range of deficits in Part I reports from an interview study based on conceptual developments, body image and aware- qualitative research methods. The study demon- ness and individuation. strates how bodily sensations and qualities like Finally, this Part III, building on research results hunger, size, weight and shape are physical entities and theory in the preceding texts, and on clinical that represent mental states. The overall finding is experience, deals exclusively with the psychother- the isomorphism between inner and outer reality, apy of anorexia. The first section of the paper mind and body. The patients demonstrate a describes the ‘model on mentalisation’. The second closeness, a more or less immediate connection section applies these conceptual tools to describe between physical and psychological realities; for more precisely the difficulties, limitations and example restrictive control of food represents hindrances to psychotherapy with anorexia ner- psychological self-control. The ‘as if’ of mental vosa. And, based on these descriptions, the third representation is turned into an ‘is’. Most persons section will outline some basic approaches and with anorexia nervosa experience this corporeality goals in therapy. Psychotherapeutic enterprise with as an obsessional and ruthless reality which is individuals with compromised mentalising capacity difficult to escape from. This concretisation of should be an activity that is specifically focused on the mental life is interpreted as impaired ‘reflective rehabilitation of this function. In the history of function’ and ‘mentalisation, and is proposed as a interpreting anorexia there are numerous descrip- central psychopathological feature in anorexia tions of the possible symbolic meanings of symp- nervosa. toms. This text will try to move interest from the ‘Reflective function’ is the broader concept and ‘what is symbolised’ to ‘how symbolised’, from refers to the psychological processes underlying the interpretation of meaning to enhancement of func- capacity to make mental representations. This tion. concept has been described both in the psycho- analytic (Fonagy, 1989, 1991) and cognitive (e.g. Morton & Frith, 1995) psychology literatures. ‘Mentalisation’ is an aspect of reflective function, A MENTALISING THEORETICAL and can be defined as ‘keeping one’s own state, AND THERAPEUTIC PERSPECTIVE desires, and goals in mind as one addresses one’s Mentalisation own experience, and keeping another’s state, desires, and goals in mind as one interprets his or The concept mentalisation originates from French her behaviour’ (Coates, 2006 p. xv). psychoanalysis (Lecours & Bouchard, 1997; Luquet, Part II develops further theoretical concepts to 1987; Marty, 1990) in the late 1960s, but diversified discuss the empirical findings and to describe in the early 1990s when Baron-Cohen (1995), Frith impairment of reflective function in anorexia and Frith (2003) and others applied it to neurobio- nervosa. When psychic reality is poorly integrated, logical based deficits in autism and schizophrenia, the body may take on an excessively central role for and, concomitantly, Fonagy, Target and colleagues the continuity of the sense of self, literally being a (Fonagy & Target, 1996, 1997; Fonagy, Gergely, body of evidence. Not being able to feel themselves Jurist, & Target, 2002) applied it to developmental from within, the patients are forced to experience psychopathology in the context of attachment Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007) DOI: 10.1002/erv Mentalisation-Based Psychotherapy for Anorexia Nervosa 325 relationships gone awry. This text leans on works in not only good for you but it is even better for your the latter tradition (Allen & Fonagy, 2006). Anthony children’ (Coates, 2006 p. xvi–xvii). Bateman has together with Peter Fonagy been a In summary, mentalisation has been empirically pioneer in translating theoretical principles into linked to important findings in development, both therapeutic principles (Bateman & Fonagy, 2004). in neuroscience and clinical psychology; in the The scientific and clinical staffs at The Menninger understanding of psychopathology; and in the Clinic in Texas, USA, are also important contribu- conceptualisation of treatment efficacy both in tors, with Jon G. Allen (Allen, 2001, 2003, 2006) as a children and adults. ‘What we have here is some- prominent professional. thing of a conceptual revolution, one that is still The model is based on developmental psychology underway’ (Coates, 2006 p. xvii). and contemporary psychoanalysis, and, not least, The concept may for some appear to have a with a strong ambition to integrate recent develop- dehumanising and technical ring to it, and should ments in neuroscience. The model also includes be humanised. We must keep in mind that the revised versions of ‘attachment theory’. Originally mental states perceived and the processes of Bowlby (1969) described the human biological urge perception are suffused with emotion; hence, to search for a secure base of attachments for mentalising is a form of emotional knowing (Allen, survival and development. Attachment is seen as an 2006). Mentalising is the normal ability to ascribe innate biological instinct to ensure protections and intentions and meaning to human behaviour, to reproduction through physical proximity to care- understand ‘unwritten rules’,